nach oben

Journal of Orthopaedic Surgery and Research

Erschienen in:

Open Access 01.12.2017 | Research article

Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials

verfasst von: Tao-ping Chen, Yu-min Chen, Jian-bao Jiao, Yun-fei Wang, Li-gang Qian, Zhao Guo, Zheng Ma, Cui-yu Han, Tong-huan Shi

Erschienen in: Journal of Orthopaedic Surgery and Research | Ausgabe 1/2017

Abstract

Background

This study aims to compare the effectiveness and safety of topical versus intravenous tranexamic acid (TXA) in reducing blood loss in primary total knee arthroplasty (TKA).

Methods

PubMed, Embase, the Cochrane Library, Web of Science, Chinese Biomedicine Literature (CBM), Wanfang Database and China National Knowledge Infrastructure (CNKI), and Google Scholar were searched for randomized controlled studies (RCTs) that compared topical versus intravenous TXA in terms of reducing blood loss during TKA from their inception to September 2015. This systematic review and meta-analysis was performed according to PRISMA criteria.

Results

Twelve studies reporting 12 RCTs comprising 1130 patients were included. Compared with the intravenous administration of TXA, the topical administration of TXA showed no significant differences in total blood loss (MD 2.08, 95% CI −68.43 to 72.60, P = 0.95), blood loss in drainage (MD 18.49, 95% CI −40.01 to 76.98, P = 0.54), hidden blood loss (MD 4.75, 95% CI −337.94 to 347.44, P = 0.99), need for transfusion (RR = 0.92, 95% CI 0.67~1.25, P = 0.58), hemoglobin (Hb) decline (MD −0.42, 95% CI −0.89 to 0.05, P = 0.08), and DVT occurrence (RR = 1.17, 95% CI 0.55~2.50, P = 0.68).

Conclusions

Compared with intravenous administration TXA, topical administration TXA exhibits comparable effectiveness and safety in terms of reducing blood loss during TKA. Due to the poor quality of the included studies, more high-quality RCTs are needed to identify the optimal method and dose of TXA after TKA.

CBM

Chinese Biomedicine Literature

Confidence interval

CNKI

China National Knowledge Infrastructure

DVT

Deep venous thrombosis

Intravenous

Mean differences

Mesh

Medical subject heading

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCTs

Randomized controlled trials

Relative risk

TKA

Total knee arthroplasty

TXA

Tranexamic acid

Background

Total knee arthroplasty (TKA) is an effective treatment that helps to relieve severe pain and handicap induced by knee joint disease. However, TKA may cause significant perioperative blood loss ranging from 800 to 1800 mL, and 10 to 38% of patients need allogeneic blood transfusion [1‐5]. Blood loss and subsequent blood transfusion can increase cost, and many complications, such as infection with HIV or other infectious diseases, fluid overload, and graft-versus-host disease can occur [6].

Many methods have been used to decrease blood loss during TKA, including the use of tourniquet, fibrin sealant, and tranexamic acid (TXA) [7‐9]. The hemostasis effect of tourniquet in TKA is controversial. Wang et al. [10] revealed that total and intra-operative blood losses were reduced only with long-duration tourniquet use, while Zhang et al. [11] found that tourniquet release at the end of the TKA will activate local fibrinolysis and might increase blood loss. Auguilera et al. [12] reported that TXA can be more effective than fibrin sealant in reducing postoperative bleeding and transfusion requirement and that fibrin sealant use was not superior to routine hemostasis.

The use of TXA in primary TKA is today widely accepted, and several studies and meta-analyses have confirmed the efficacy of TXA at decreasing blood loss without increasing complications and costs [9, 13, 14]. Several clinical trials have identified that intravenous (IV) TXA is effective in reducing perioperative blood loss and the need for subsequent blood transfusions in TKA [15‐17]. However, deep venous thrombosis (DVT) after the systemic administration of TXA is still a serious and fatal complication [18]. Therefore, many researchers have focused on the topical application of TXA via drain tube or intra-articular administration, and the topical application of TXA is considered an alternative effective route that entails less risk than IV after TKA [19, 20]. A previous meta-analysis has been published that only included five RCTs and one non-RCT [21]. Nevertheless, the comparative efficacy and safety of topical versus intravenous TXA often differs between studies. Thus, we performed a meta-analysis to compare the effectiveness and safety of topical versus intravenous TXA after TKA.

Methods

Search strategy

The following electronic databases were searched: PubMed, Embase, the Cochrane Library, Web of Science, Chinese Biomedicine Literature (CBM), Wanfang Database and China National Knowledge Infrastructure (CNKI), and Google Scholar were searched by two reviewers. Relevant studies comparing the topical administration of TXA and intravenous TXA for the management of blood loss during TKA were identified by two reviewers; the search was performed in August 2015. The keywords and Medical Subject heading (MeSH) terms used for the search were the following: “TXA,” “tranexamic acid” “total knee arthroplasty,” “total knee replacement”, “TKA”, “TKR”, and “Arthroplasty, Replacement, Knee”[Mesh]; the terms were connected by the Boolean operators AND or OR. The search string used in our research is presented in appendix A. Additionally, the reference lists of all identified full-text articles were reviewed to identify any initially omitted studies. There were no restrictions regarding language. Since this is a meta-analysis, no ethics committee or institutional review board approval was required.

Eligibility criteria and study quality

Study selection was performed according to the following inclusion criteria: (1) studies of patients undergoing primary TKA intervention; (2) with topical administration TXA and intravenous TXA as therapy to control blood loss; (3) studies assessing primary outcomes such as total blood loss, blood loss in drainage, hidden blood loss, need for transfusion, hemoglobin decline, and the rate of complications (DVT); and (4) studies designed as randomized controlled trials (RCTs). All the studies were required to be clinical trials. Trials on cadavers or artificial models were excluded. Letters, comments, editorials, and practice guidelines were also excluded.

According to the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0) [22], Review Manager, version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014) was used to describe the quality assessment.

Data extraction

Two reviewers independently extracted and recorded following data in a spreadsheet: (1) patient demographic data, author’s name, publication date, sample size, location of study, ratio of male and female subjects, the dose and method of TXA application (topical or intravenous), and whether TKA was unilateral or bilateral; (2) the method of anesthesia; and (3) total blood loss, blood loss in drainage, hidden blood loss, need for transfusion, hemoglobin decline and rate of complications (deep venous thrombosis (DVT)). If the data were presented as figures, the software “Getdata Graph Digitizer” was used to extract the data for meta-analysis.

Outcome measures and statistical analysis

The main parameters studied were total blood loss, blood loss in drainage, hidden blood loss, need for transfusion, hemoglobin decline, and rate of complications (DVT). Hidden blood loss (mL) was calculated as total blood loss minus blood loss collected from drains. The results are presented as the mean differences (MDs) with 95% confidence interval (CI) for continuous outcomes such as total blood loss and blood loss in drainage. Binary outcomes, such as the need for transfusion and the occurrence of DVT were presented as relative risk (RR) values with 95% CI. Statistical significance was set at P < 0.05. To summarize findings across the trials, the software RevMan 5.3 (The Cochrane Collaboration, Oxford, UK) was used to conduct the meta-analysis. Statistical heterogeneity was tested using the chi-squared test and the I ² statistic. Chi-squared test results with P > 0.1 were considered suggestive of statistical heterogeneity. An I ² statistic greater than 50% was considered to indicate substantial heterogeneity [23]. A fixed effect model was adopted if the I ² statistic value was less than 50%. If the I ² statistic value was greater than 50%, a sensitivity analysis was performed using Stata 12.0 (Stata Corp., College Station, TX, USA) to explore the effect of an individual study.

Results

Search result and quality assessment

The initial search yielded 385 potentially relevant studies; of these, no duplicate was found using Endnote Software. Based on the inclusion criteria, 374 studies were excluded after reading the titles and abstracts. Finally, 12 clinical trials involving 1130 patients were included in the meta-analysis [24‐36]. The process for selecting the included studies is presented in Fig. 1. One study included four IV groups [30], and one report included two topical groups that differed in the dose and timing administration of TXA [32]. Differently dosed TXA groups were included in this meta-analysis. The characteristics of the included studies are shown in Table 1, and the doses and methods used to apply TXA are summarized in Table 2. In the included studies, 1130 TKAs were performed, and the numbers of topical TXA and intravenous TXA were 529 and 601, respectively. Eight articles were in English, and four studies were in Chinese; all were published between 2013 and 2015. All participants in the 12 studies were elderly patients aged between 42 and 72.5 years who were planning to undergo TKA. Tourniquet was applied in all of the included studies, and the pressure of the tourniquet ranged from 100 to 350 mmHg. Detailed information regarding the risk of bias in the included studies is shown in Figs. 2 and 3.

Table 1

Characteristics of included studies

Authors	Patients (T/I)	Age (mean year) (C/I)	Gender (F/M)	Diagnosis	Country	Type of prosthesis	Surgical protocol	Pneumatic tourniquet	Follow-up
Patel JN 2014 [31]	47/42	42/64.9	23/66	OA	USA	ns	Con-TKA	Yes	4.6
Maniar RN 2012 [30]	40/160	67.4/67.45	42/158	OA	India	Cemented	CAS-TKA	Yes	3
Seo JG 2013 [33]	50/50	67.5/66.8	11/89	OA	Korea	Cemented	CAS-TKA	Yes	2
Sarzaeem MM 2014 [32]	100/50	67.8/66.9	20/130	OA	Iran	Cemented	Con-TKA	Yes	–
Soni A 2014 [34]	40/40	69.45/69.05	36/44	OA	India	Cemented	Con-TKA	Yes	1.5
Tang Lian 2014 [29]	30/30	66.5/67.1	20/40	OA	China	ns	Con-TKA	Yes	–
Han WF 2014 [26]	50/50	ns	20/80	OA + RA	China	Cemented	Con-TKA	Yes	3 months
Aguilera X 2015 [24]	50/50	72.53/72.49	70/30	OA + RA + DKD	Spain	Cemented	Con-TKA	Yes	2
Digas G 2015 [25]	30/30	70/71	51/49	OA	Germany	Cemented	Con-TKA	Yes	25 days
Jiang Hua 2015 [28]	33/40	ns	54/19	DKD	China	ns	Con-TKA	Yes	7 days
Hou ZY 2015 [36]	20/20	67.36/67.02		OA + RA	China	Uncemented	Con-TKA	Yes	14 days

NS not stated, T topical group, I intravenous group, OA osteoarthritis, RA rheumatoid arthritis, DKD degenerative knee disorders, Con-TKA conventional total knee arthroplasty, CAS-TKA computer-assisted total knee arthroplasty

Table 2

Dose and method for topical and intravenous administration of TXA

Author/s	Intervention		Methods of administration the tranexamic acid		Transfusion criteria	Thromboprophylaxis
Author/s	Topical	IV	Topical	IV	Transfusion criteria	Thromboprophylaxis
Gomez-Barrenna 2014 [27]	3 g/100 mL	15 mg/kg. 2 doses	One dose irrigated before joint closure, and the other half was administered intra-articularly after skin closure	Fifteen to 20 min before tourniquet release and 100 mL 3 h	Hb <80 g/L	NS
Patel JN 2014 [31]	2 g TXA/ 100 mL NS	10 mg/kg ∗ 1 dose	2 min TA before tourniquet release, with drain	One dose as IO	Hb b 8.0 g/dL + symptom	LMWH
Maniar RN 2012 [30]	3 g TXA/100 mL NS	10 mg/kg ∗ 1 dose 10 mg/kg ∗ 2 doses 10 mg/kg ∗ 2 doses 10 mg/kg ∗ 3 doses	5 min TXA before tourniquet release, clamp drain 2 h then fully open	One dose as IO Two doses as IOPO Two doses as POIO Three doses at POIOPO	Hb b 8.5 g/dL Hb b 10.0 g/dL + symptom	LMWH
Seo JG 2013 [33]	1.5 g TXA/100 mL	1.5 g TXA/100 mL, NS	IXA while suturing, with no clamp drain	One dose at post-operative	Hb b 8.0 g/dL Hb b 10.0 g/dL + symptoms	NS
Sarzaeem MM 2014 [32]	1.5 gTXA/100 mL NS 3.0 gTXA/100 mL NS	1.5 g TXA/100 mL, NS	1.5 g TXA: IXA injected through the drain after wound closure 3 g TXA: 5 min TXA before suturing, clamp drain 1 h then fully open	One dose at post-operative	Hb b 7.0 g/dL Hb b 10.0 g/dL + symptom	NS
Soni A 2014 [34]	3 g TXA/100 mL	10 mg/kg ∗ 3 doses	5 min TXA before tourniquet release, clamp drain 2 h then fully open	Three doses as POIOPO	Hb b 8.0 g/dl	LMWH
Tang Lian 2014 [29]	500 mg/5 mL	10 mg/5 mL	Intra-articular injection after suction without drain	Intravenous 15 min before tourniquet release	Hb <90 g/L	LMWH
Han Wenfeng 2014 [26]	1 g/50 mL	15 mg/kg, maximum 1.2 g	Spray the TXA before suction and clamp drain for 30 min then fully open	Induction of general anesthesia	Hb <70 g/L	LMWH
Aguilera X 2015 [24]	1 g/10 mL	1 g * 2 doses	The TXA was applied by syringe spray and drain was kept closed during the first hour and removed 24 h after surgery	Patients in the control group received a slow IV infusion	Hb <80 g/L Hb <80 g/L + symptoms between 8.5 and 9 g/dL + symptoms	LMWH
Digas G 2015 [25]	2 g	15 mg/kg 1 dose	Intra-articular	Before deflation of the tourniquet	Hb <85 g/L Hb <95 g/L + symptoms	3.500 IU of tinzaparin
Jiang Hua 2015 [28]	2 g/100 mL	10 mg/kg 1 dose	Intra-articular	Before closing the wound	NS	Enoxaparin and Rivaroxaban
Hou zhenyang 2015 [36]	500 mg/10 mL	10 mg/kg 1 dose	Intra-articular	Before insert the prosthesis	Hb <70 g/L	Rivaroxaban

NS not stated, Hb hemoglobin, LMWH low molecular weight heparin, IO intra-operative, IOPO intra-operative and postoperative, POIO postoperative and intra-operative, POIOPO postoperative, intra-operative, and postoperative, TXA tranexamic acid

Meta-analysis results

Blood loss (total blood loss, blood loss in drainage, and hidden blood loss)

Five trials [12, 25, 27, 29, 30] reported data on topical versus intravenous administration for reducing total blood loss after TKA. Statistical heterogeneity was found (χ ² = 41.56, I ² = 83%, P < 0.00001, Fig. 4), and a random-effects model was performed. Topical administration of TXA showed no significant difference (MD2.08, 95% CI −68.43 to 72.60, P = 0.95, Fig. 4) in reducing total blood loss compared with intravenous TXA. A total of 10 studies [24‐28, 32‐34, 36] compared topical versus intravenous TXA in terms of reducing blood loss in drainage. Statistical heterogeneity (χ ² = 864.26, I ² = 98%, P < 0.00001, Fig. 4) occurred, and a random-effects model was performed. Similarly, the topical application of TXA did not significantly decreased the blood loss in drainage after TKA (MD18.49, 95% CI −40.01 to 76.98, P = 0.54, Fig. 4) compared with intravenous administration. For hidden blood loss, statistical heterogeneity (χ ² = 39.60, I ² = 95%, P < 0.00001, Fig. 4) was found, and a random-effects model was performed. There was no significant difference between the topical and intravenous groups (MD 4.75, 95% CI −337.94 to 347.44, P = 0.99, Fig. 4).

Need for transfusion

Fifteen studies [24‐27, 29‐34, 36] mentioned a need for transfusion in 1206 enrolled knees. No significant heterogeneity (χ ² = 13.20, I ² = 2%, P = 0.43) was found. This paper uses a fixed-effects model, and no significant difference was found between topical TXA groups and intravenous TXA groups regarding the need for transfusion (RR = 0.92, 95% CI 0.67~1.25, P = 0.58) (Fig. 5).

Hemoglobin decline

No significant difference was found between the IV TXA with topical TXA groups (MD-0.42, 95% CI −0.89 to 0.05, P = 0.08, Fig. 6). Statistical heterogeneity (χ ² = 107.72, I ² = 94%, P < 0.00001, Fig. 6) exists, and a random-effects model was performed. To eliminate heterogeneity, a subgroup analysis was carried out for hemoglobin decline (Table 3).

Table 3

Subgroup analysis for the hemoglobin drop

Outcome or subgroup	Studies	Effect estimate
		χ ²	I ²(%)	MD	95% CI	P value
Non-computer navigated TKR	4	190.77	98	0.31	−1.26,1.89	0.7
High score RCT	3	193.26	97	0.11	−0.89,1.11	0.83

Thromboembolic complications

Fourteen studies provided data about the rate of thromboembolic complications; the results of the meta-analysis indicate that the rate of thromboembolic complications for the intravenous group is 1.93% and that for the topical group is 1.58%; no significant difference was found between the two groups (RR = 1.17, 95% CI 0.55~2.50, P = 0.68, Fig. 7). No statistically heterogeneity (χ ² = 5.72, I ² = 0%, P = 0.68, Fig. 7) was found; therefore, a fixed-effects model was performed.

Other outcomes

Since the sample of other identified outcomes was not large enough for meta-analysis, we performed a descriptive analysis. For instance, Seo [33] found no significant difference between the range of motion between the two groups; the average ranges of motion (ROMs) at 2 months were 2.6°–123.3° and 2.5°–120.4° in the intravenous and intra-articular groups, and no significant difference was found in the intergroup analysis. The ranges of motion 1 month postoperatively were 104° ± 10° (95% CI, 101° to 108°) in the topical group and 105° ± 11 (95% CI, 101° to 109°) in the intravenous group (P = 0.612) [27]. There were 0 and 1 cases of atrial fibrillation in the topical TXA and IV TXA groups, respectively. Saezaeem [32] reported just one postoperative complication in the injected TXA group; this involved a patient with skin necrosis and more joint swelling than that seen for the intravenous group. One case of acute kidney injury was found in each of the topical and IV TXA groups [31].

Sensitivity analysis

A sensitivity analysis of blood loss in drainage was conducted, and the results indicated that none of the studies affected the stability of the final results (Fig. 8).

Discussion

The results of the current meta-analysis indicate that there were no significant differences in total blood loss, blood loss in drainage, hidden blood loss, need for transfusion, and minimal hemoglobin decline between topical TXA and IV TXA groups in primary TKA. Moreover, no significant difference was found in the rate of DVT between the two groups. Moreover, no adverse effects were reported in the included studies.

Patients undergoing TKA may suffer from large blood loss due to the large area of osteotomy and enhanced local fibrinolysis after tourniquet release [37]. Total blood loss can be 300 mL higher than that occurring with no tourniquet use. Thus, the topical administration of TXA can reduce postoperative blood loss when combined with the use of a drainage clamp. Furthermore, Jawhar et al. [38] reported that tourniquet use can induce ischemia during TKA and can result in higher proteolytic activity within vastus medialis cells, which may increase hidden blood loss. Compared with intravenous TXA administration, intra-articular TXA administration can be rapidly absorbed, maintaining a biological half-life of approximately 3 h within the joint fluid; this may be the reason why patients benefit from topical TXA administration [39]. TXA is an antifibrinolytic agent that activates plasminogen and stops bleeding without increasing plasma fibrin levels [40]. Several studies and meta-analyses have identified TXA as an efficacious and safe way to reduce blood loss in patients who undergo TKA [41‐43], and numerous studies have focused on the efficacy of topical TXA administration in reaching a maximum hemostatic effect [44‐46]. However, the most effective TXA regimen in primary TKA remains uncertain. A meta-analysis on outcomes was previously conducted to explore the difference between the two groups [21]. However, in their study, five RCTs and one prospective cohort study were included; moreover, they did not compare hidden blood loss between the two groups. The current meta-analysis included twelve studies and did compare hidden blood loss, which comprises a large proportion of total blood loss.

With regard to the need for transfusion, no significant difference was found between the two groups (RR = 0.92, 95% CI 0.67~1.25, P = 0.58); the dose of topical administration ranged from 0.5 to 3 g, and the dose of intravenous TXA administration ranged from 10 to 15 mg/kg. Three studies reported hidden blood loss for the two groups, and Aguilera [24] favors the use of topical administration to reduce hidden blood loss after TKA, whereas Hou and colleagues [47] found no difference between topical and intravenous administration. In this meta-analysis, no significant difference between topical and IV TXA administration was found. Our sensitivity analysis showed that the study of Sarzaeem [32] significantly affected the heterogeneity results. After carefully reviewing the study, the main difference between this study and the other studies is that TXA was administered by irrigating with 3 g of TXA and injecting with 1.5 g TXA. In addition, doses of topically administered TXA ranging from 0.5 g [48] to 3 g [27, 30, 34, 44, 49] have all proven effective and safe. Regarding blood loss in drainage, a large degree of heterogeneity was found between the two groups, and the sensitivity analysis showed that the inclusion of Sarzaeem’s study influences the final conclusion. After carefully reading the article, the topical administration of TXA was applied by irrigation.

DVT and subsequent PE are fatal complications after TKA, and it has been reported that 0.1–2% of patients will suffer from pulmonary embolism following TKA [50]. Theoretically, intravenous TXA administration may increase the risk of thrombosis since it is a synthetic antifibrinolytic agent that can prevent plasminogen activation, and fibrinolysis is delayed [51]. However, it has been ascertained that TXA does not inhibit fibrinolytic activity in the vein wall, and its effect on disrupted endothelium remains unknown [52]. The results of the current meta-analysis indicate that both topical and intravenous administration TXA are safe when used to reduce blood loss during TKA. The frequencies of DVT after intravenous and topical TXA administration are 11/571 and 9/568, respectively (RR = 1.17, 95%CI 0.55~2.50, P = 0.68). The reasons for this may be as follows: (1) the doses used during intravenous and topical administrations are appropriate and do not exceed the optimal dose; therefore, the fibrinolytic system will not be suppressed. (2) Most studies only evaluated symptomatic DVT and PE, and this will have affected the final conclusion.

This meta-analysis has the following limitations: (1) Only twelve studies were included, and the sample sizes used in each study were insufficient, which will affect the conclusions. (2) The studies administered TXA at different doses and using different methods, causing large heterogeneity. (3) The duration of follow-up in some studies was short; therefore, long-term follow-up is needed to measure the occurrence of DVT and PE.

Conclusions

In conclusion, this meta-analysis indicated that topical TXA administration exhibits comparable efficacy and safety to those of intravenous TXA, and both methods can decrease the need for transfusion, total blood loss, blood loss in drainage, and hidden blood loss without increasing the occurrence of DVT. Due to the poor quality of the included studies, more high-quality RCTs are needed to identify the optimal method and dose of TXA after TKA.

Acknowledgements

No funding was required for this systematic review and meta-analysis.

Availability of data and materials

We state that the data will not be shared since all raw data used are presented in the figures that are included in the article.

Authors’ contributions

TPC conceived the study design. YMC, JBJ, and YFW performed the study, collected the data, and contributed to the study design. LGQ, ZG, and ZM prepared the manuscript. CYH and THS edited the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Not applicable.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Bong MR, Patel V, Chang E, Issack PS, Hebert R, Di Cesare PE. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty. 2004;19:281–7.CrossRefPubMed

Goodnough LT, Verbrugge D, Marcus RE. The relationship between hematocrit, blood lost, and blood transfused in total knee replacement. Implications for postoperative blood salvage and reinfusion. Am J Knee Surg. 1995;8:83–7.PubMed

Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee. 2000;7:151–55.CrossRefPubMed

Lotke PA, Faralli VJ, Orenstein EM, Ecker ML. Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am. 1991;73:1037–40.CrossRefPubMed

Hiippala S, Strid L, Wennerstrand M, et al. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth. 1995;74:534–7.CrossRefPubMed

Madjdpour C, Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth. 2005;95:33–42.CrossRefPubMed

Li ZJ, Fu X, Tian P, et al. Fibrin sealant before wound closure in total knee arthroplasty reduced blood loss: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2015;23:2019–25.CrossRefPubMed

Na YG, Bamne AB, Won HH, Kim TK. After early release of tourniquet in total knee arthroplasty, should it be reinflated or kept deflated? A randomized trial. Knee Surg Sports Traumatol Arthrosc. 2015.

Wei Z, Liu M. The effectiveness and safety of tranexamic acid in total hip or knee arthroplasty: a meta-analysis of 2720 cases. Transfus Med. 2015;25:151–62.CrossRefPubMed

10.

Wang K, Ni S, Li Z, et al. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016.

11.

Zhang W, Liu A, Hu D, Tan Y, Al-Aidaros M, Pan Z. Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2014;9:125.CrossRefPubMedPubMedCentral

12.

Aguilera X, Martinez-Zapata MJ, Bosch A, et al. Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial. J Bone Joint Surg Am. 2013;95:2001–7.CrossRefPubMed

13.

Yue C, Pei F, Yang P, Xie J, Kang P. Effect of topical tranexamic acid in reducing bleeding and transfusions in TKA. Orthopedics. 2015;38:315–24.CrossRefPubMed

14.

Wu Q, Zhang HA, Liu SL, Meng T, Zhou X, Wang P. Is tranexamic acid clinically effective and safe to prevent blood loss in total knee arthroplasty? A meta-analysis of 34 randomized controlled trials. Eur J Orthop Surg Traumatol. 2015;25:525–41.CrossRefPubMed

15.

Fu DJ, Chen C, Guo L, Yang L. Use of intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials. Chin J Traumatol. 2013;16:67–76.PubMed

16.

Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31:529–37.PubMed

17.

Sabatini L, Atzori F, Revello S, Scotti L, Debiasi F, Masse A. Intravenous use of tranexamic acid reduces postoperative blood loss in total knee arthroplasty. Arch Orthop Trauma Surg. 2014;134:1609–14.CrossRefPubMed

18.

Raveendran R, Wong J. Tranexamic acid reduces blood transfusion in surgical patients while its effects on thromboembolic events and mortality are uncertain. Evid Based Med. 2013;18:65–6.CrossRefPubMed

19.

Martin JG, Cassatt KB, Kincaid-Cinnamon KA, Westendorf DS, Garton AS, Lemke JH. Topical administration of tranexamic acid in primary total hip and total knee arthroplasty. J Arthroplasty. 2014;29:889–94.CrossRefPubMed

20.

Alshryda S, Mason J, Vaghela M, et al. Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total knee replacement: a randomized controlled trial (TRANX-K). J Bone Joint Surg Am. 2013;95:1961–8.CrossRefPubMed

21.

Wang H, Shen B, Zeng Y. Comparison of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled and prospective cohort trials. Knee. 2014;21:987–93.CrossRefPubMed

22.

Higgins JPT GS. Cochrane handbook for systematic reviews of interventions version 5.1.0. 2011.http://handbook.cochrane.org.

23.

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60.CrossRefPubMedPubMedCentral

24.

Aguilera X, Martinez-Zapata MJ, Hinarejos P, et al. Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial. Arch Orthop Trauma Surg. 2015;135:1017–25.CrossRefPubMed

25.

Digas G, Koutsogiannis I, Meletiadis G, Antonopoulou E, Karamoulas V, Bikos C. Intra-articular injection of tranexamic acid reduce blood loss in cemented total knee arthroplasty. Eur J Orthop Surg Traumatol. 2015.

26.

Han W, Zhang L, Zhang P, Zhang J. Function of topical (intra-articular) tranexamic acid versus intravenous tranexamic acid in reducing blood loss following total knee replacement: a comparative study (Chinese). Int J Orthod. 2014;35:269–71.

27.

Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Perez-Chrzanowska H, Figueredo-Zalve R. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am. 2014;96:1937–44.CrossRefPubMed

28.

Jiang H, Yan Y, Ma H, Zeng Y, Xu B, Wang J. Comparison of effects on intravenous and intra-articular cavity injection of tranexamic acid on blood loss volume in total knee arthroplasty (Chinese). China Pharmaceuticals. 2015;44–45:46.

29.

Tang L. Effect of tranexamic acid on blood loss in vein and joint of patients with total knee arthroplasty (Chinese). Chinese J Biochemical Pharmaceutics. 2014; 105–07.

30.

Maniar RN, Kumar G, Singhi T, Nayak RM, Maniar PR. Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients. Clin Orthop Relat Res. 2012;470:2605–12.CrossRefPubMedPubMedCentral

31.

Patel JN, Spanyer JM, Smith LS, Huang J, Yakkanti MR, Malkani AL. Comparison of intravenous versus topical tranexamic acid in total knee arthroplasty: a prospective randomized study. J Arthroplasty. 2014;29:1528–31.CrossRefPubMed

32.

Sarzaeem MM, Razi M, Kazemian G, Moghaddam ME, Rasi AM, Karimi M. Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty. J Arthroplasty. 2014;29:1521–4.CrossRefPubMed

33.

Seo JG, Moon YW, Park SH, Kim SM, Ko KR. The comparative efficacies of intra-articular and IV tranexamic acid for reducing blood loss during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013;21:1869–74.CrossRefPubMed

34.

Soni A, Saini R, Gulati A, Paul R, Bhatty S, Rajoli SR. Comparison between intravenous and intra-articular regimens of tranexamic acid in reducing blood loss during total knee arthroplasty. J Arthroplasty. 2014;29:1525–7.CrossRefPubMed

35.

Xi S, Chaobo Z, Guilin Z. Hemostatic effect of local application and intravenous application of tranexamic acid in total knee arthroplasty (Chinese). Practical Pharmacy and Clinical Remedies. 2015; 481–84.

36.

Hou Z-y, Su C-z, Pang T, et al. Primary unilateral cemented total knee arthroplasty: effect of tranexamic acid usage on blood loss (Chinese). Chinese Journal of Tissue Engineering Research. 2015;19:1329–34.

37.

Jorn LP, Lindstrand A, Toksvig-Larsen S. Tourniquet release for hemostasis increases bleeding: a randomized study of 77 knee replacements. Acta Orthop. 1999;70:265–67.CrossRef

38.

Jawhar A, Hermanns S, Ponelies N, Obertacke U, Roehl H. Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2015; 1–9.

39.

Hiippala ST, Strid LJ, Wennerstrand MI, et al. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg. 1997;84:839–44.CrossRefPubMed

40.

Sukeik M, Alshryda S, Haddad F, Mason J. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br Vol. 2011;93:39–46.CrossRef

41.

Zhang H, Chen J, Chen F, Que W. The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2012;20:1742–52.CrossRefPubMed

42.

Yang Z-G, Chen W-P, Wu L-D. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg. 2012;94:1153–59.CrossRefPubMed

43.

Kim TK, Chang CB, Koh IJ. Practical issues for the use of tranexamic acid in total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2014;22:1849–58.CrossRefPubMed

44.

Wong J, Abrishami A, El Beheiry H, et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty. J Bone Joint Surg. 2010;92:2503–13.CrossRefPubMed

45.

Roy SP, Tanki UF, Dutta A, Jain SK, Nagi ON. Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012;20:2494–501.CrossRefPubMed

46.

Konig G, Hamlin BR, Waters JH. Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty. J Arthroplasty. 2013;28:1473–76.CrossRefPubMed

47.

Zheng-wen HZ-ySC-zPTLDZBSY-lLZCX-yX. Primary unilateral cemented total knee arthroplasty: effect of tranexamic acid usage on blood loss. Chinese J Tissue Engineering Res. 2015;19:1329–34.

48.

Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br Vol. 2001;83:702–05.CrossRef

49.

Gilbody J, Dhotar HS, Perruccio AV, Davey JR. Topical tranexamic acid reduces transfusion rates in total hip and knee arthroplasty. J Arthroplasty. 2014;29:681–84.CrossRefPubMed

50.

Bosque Jr J, Coleman SI, Di Cesare P. Relationship between deep vein thrombosis and pulmonary embolism following THA and TKA. Orthopedics. 2012;35:228–33. quiz 34–5.CrossRefPubMed

51.

Hamlin BR, DiGioia AM, Plakseychuk AY, Levison TJ. Topical versus intravenous tranexamic acid in total knee arthroplasty. J Arthroplasty. 2015;30:384–86.CrossRefPubMed

52.

Astedt B, Liedholm P, Wingerup L. The effect of tranexamic acid on the fibrinolytic activity of vein walls. Ann Chir Gynaecol. 1978;67:203–5.PubMed

Titel: Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials
verfasst von: Tao-ping Chen
Yu-min Chen
Jian-bao Jiao
Yun-fei Wang
Li-gang Qian
Zhao Guo
Zheng Ma
Cui-yu Han
Tong-huan Shi
Publikationsdatum: 01.12.2017
Verlag: BioMed Central
Erschienen in: Journal of Orthopaedic Surgery and Research / Ausgabe 1/2017
Elektronische ISSN: 1749-799X
DOI: https://doi.org/10.1186/s13018-017-0512-4

Arthropedia

Grundlagenwissen der Arthroskopie und Gelenkchirurgie. Erweitert durch Fallbeispiele, Videos und Abbildungen.
» Jetzt entdecken

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Notfall-TEP der Hüfte ist auch bei 90-Jährigen machbar

26.04.2024 Hüft-TEP Nachrichten

Ob bei einer Notfalloperation nach Schenkelhalsfraktur eine Hemiarthroplastik oder eine totale Endoprothese (TEP) eingebaut wird, sollte nicht allein vom Alter der Patientinnen und Patienten abhängen. Auch über 90-Jährige können von der TEP profitieren.

Arthroskopie kann Knieprothese nicht hinauszögern

25.04.2024 Gonarthrose Nachrichten

Ein arthroskopischer Eingriff bei Kniearthrose macht im Hinblick darauf, ob und wann ein Gelenkersatz fällig wird, offenbar keinen Unterschied.

Therapiestart mit Blutdrucksenkern erhöht Frakturrisiko

25.04.2024 Hypertonie Nachrichten

Beginnen ältere Männer im Pflegeheim eine Antihypertensiva-Therapie, dann ist die Frakturrate in den folgenden 30 Tagen mehr als verdoppelt. Besonders häufig stürzen Demenzkranke und Männer, die erstmals Blutdrucksenker nehmen. Dafür spricht eine Analyse unter US-Veteranen.

Ärztliche Empathie hilft gegen Rückenschmerzen

23.04.2024 Leitsymptom Rückenschmerzen Nachrichten

Personen mit chronischen Rückenschmerzen, die von einfühlsamen Ärzten und Ärztinnen betreut werden, berichten über weniger Beschwerden und eine bessere Lebensqualität.

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Search strategy

Eligibility criteria and study quality

Data extraction

Outcome measures and statistical analysis

Results

Search result and quality assessment

Meta-analysis results

Blood loss (total blood loss, blood loss in drainage, and hidden blood loss)

Need for transfusion

Hemoglobin decline

Thromboembolic complications

Other outcomes

Sensitivity analysis

Discussion

Conclusions

Acknowledgements

Availability of data and materials

Authors’ contributions

Competing interests

Consent for publication

Ethics approval and consent to participate

Weitere Artikel der Ausgabe 1/2017

Analysis of factors that affect the precision of the radiographic lateral femoral bowing angle using a three-dimensional computed tomography-based modelling technique

Results of 167 consecutive cases of acetabular fractures using the Kocher-Langenbeck approach: a case series

Effect of oxidative stress induced by intracranial iron overload on central pain after spinal cord injury

Percutaneous transforaminal endoscopic surgery (PTES) for symptomatic lumbar disc herniation: a surgical technique, outcome, and complications in 209 consecutive cases

The evaluation of the role of medial collateral ligament maintaining knee stability by a finite element analysis

Cortisol inhibits mTOR signaling in avascular necrosis of the femoral head

Arthropedia

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Notfall-TEP der Hüfte ist auch bei 90-Jährigen machbar

Arthroskopie kann Knieprothese nicht hinauszögern

Therapiestart mit Blutdrucksenkern erhöht Frakturrisiko

Ärztliche Empathie hilft gegen Rückenschmerzen

Update Orthopädie und Unfallchirurgie